MEDICARE: BROOK DIANE HODGE MS, CRC-CVE, PCLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	BBH-PCLC-LIC-74595	MT

General Provider Information

NPI Number	:	1871485953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOK DIANE HODGE MS, CRC-CVE, PCLC

Provider Business Mailing Address
First Line	:	4720 23RD AVE
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59803-1137
Country	:	US
Telephone Number	:	406-541-4663
Fax Number	:

Provider Business Practice Location Address
First Line	:	4720 23RD AVE
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59803-1137
Country	:	US
Telephone Number	:	406-541-4663
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2025
Last Update Date	:	07/15/2025

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